Every step of the way

Kris Hilgedick

Saturday

Feb 26, 2011 at 12:01 AMFeb 26, 2011 at 1:00 AM

Women’s Health Associates, the oldest continuously operating obstetrics/gynecological practice in Columbia, has 13 OB-GYNs and 60 support staff. The firm handles the bulk of Boone Hospital Center’s high-risk pregnancies and offers a full slate of gynecologic care to women of all ages.

Jennifer Lewis is eight months pregnant, but she still keeps busy working at Boone Hospital Center, taking patients from point to point. Few people would guess she suffers from high blood pressure, and her baby remains in the breech position.

Lewis, 29, of Columbia is one of an increasingly large pool of women coping with high-risk pregnancies. And, in Central Missouri, many of those women seek the assistance of Women’s Health Associates, the oldest continuously operating obstetrics/gynecological practice in Columbia.

A week ago, she sat down in a patient examination room with Kimberly Morse, one of 13 doctors at the practice.

“I have a lot of questions,” Lewis said. “My contractions are a lot more frequent.”

She said the sensations are strongest when she’s moving around.

Morse already had examined the results from Lewis’ fetal monitor. The young doctor wasn’t entirely pleased, but she didn’t want to alarm Lewis, either.

“Everything looks good, but he didn’t meet all his criteria, … so I want to do a little bit of extra monitoring,” Morse said. “Can you take off work this afternoon?”

Another session of fetal monitoring — which revealed the baby boy’s lungs were functioning properly — reassured everyone the pregnancy was progressing.

Although many pregnant women with high blood pressure have healthy babies, the condition poses a danger. It can harm the mother’s kidneys and other organs. It can lead to low birth weight and early delivery. In the most serious cases, the mother develops preeclampsia, or “toxicity of pregnancy,” which can threaten the lives of mother and child.

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The work that takes place at Women’s Health Associates is quite serious, but the practice’s serene waiting room — with its subdued lighting and padded armchairs — feels more like the lobby of a spa.

With 13 OB-GYNs and 60 support staff, Women’s Health Associates handles the bulk of Boone Hospital Center’s high-risk pregnancies and offers a full slate of gynecologic care to women of all ages.

Fred Williams founded the business in 1975 when he opened in the doctor’s park across Broadway from the Columbia Public Library. Bob McDavid — who now serves as Columbia’s mayor — joined Williams three months later, and the business was incorporated under its current name.

Lee Trammell arrived next in 1980. The three men — all natives of the Missouri Bootheel — were acquaintances who met through the University of Missouri’s medical program.

“They offered me a job, and I took it,” Trammell said. “It was the only job we had in our lives.”

In those early days, the three men shared Williams’ one-man office. “We shared a desk, and I had a little drawer,” he said. “They hired me with the promise that we would soon move into a new office in the doctor’s park.”

In 1993, they moved to a new expansive office at Broadway Medical Plaza I, where they were among the building’s first tenants. That first year, they leased more space than they needed because they knew they might expand.

McDavid and Williams have retired in recent years, leaving Trammell as the partner with the longest history still working at the practice.

During the course of Trammell’s career, he has witnessed a revolution in the way babies are birthed.

“Pregnancy is a biologic event that hasn’t changed much in eons,” he said.

But the way doctors respond has changed dramatically, he said, primarily because of the introduction of four technologies: fetal monitoring, ultrasound, epidural anesthesia and pregnancy tests that measure human chorionic gonadotropin, or hCG, hormone levels.

“When we started, it wasn’t easy to tell if someone was pregnant,” Trammell said.

Trammell was in medical school when the first fetal monitor was installed in 1973. The first ultrasound experiment at University Hospital was performed in 1978, incidentally, on Trammell’s wife. Also in the mid-1970s, doctors began to use epidurals to numb the agony of delivery.

“They used to always put the delivery rooms in the farthest corner of the hospital” because the screaming unnerved the other patients, Trammell said. “With an epidural, women can push longer and more comfortably.”

Thirty years ago, doctors could listen to a fetus’s heartbeat with a stethoscope, but they couldn’t detect patterns over time.

Early ultrasound images were grainy and didn’t tell doctors much about congenital defects, but they at least allowed a doctor to measure a baby’s size and predict its sex. McDavid would tell his patients in the 1980s: “I think it’s a girl, but don’t buy any pink stuff.”

Another major leap forward happened when Boone Hospital opened the Neonatal Intensive Care Unit in the late 1990s. That allowed Women’s Health Associates to treat more high-risk pregnancies. Before that, serious cases were sent to University Hospital.

“We didn’t deliver anyone before 34 weeks because you couldn’t predict what the needs were going to be,” McDavid said.

Trammell said: “We’ve been here as the horizons opened up.”

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The practice occupies much of the first and third floors of Broadway Medical Plaza I, a red-brick office structure at 1601 E. Broadway.

David Moreton is one of the practice’s 13 doctors, but he also functions as the corporation’s president. “I try to solve as many of the business issues as I can, so the other doctors can concentrate on their patients,” he said.

Moreton said the group has contemplated adding other sub-specialties — such as gynecological oncology or urogynecology — but decided against doing so because it would upset the practice’s on-call schedule. (Currently, the doctors cover for one another when an emergency arises or a baby needs to be delivered, but that system wouldn’t work as smoothly if other specialties were introduced.)

“We’ve thought about it, but the single-specialty model we have has worked so well,” he said.

McDavid said the practice has grown because early on he and Williams decided to make entry into the business easy.

“We made a decision it was going to be important to grow,” he said. “We made it easy for partners to join; no equity was necessary.”

With 13 doctor-partners, the practice is a relatively large one that has merged with other smaller groups over the years. But that larger size has yielded economies of scale, such as the shared use of the ultrasound machines.

All 13 partners function in the business as equal colleagues who meet monthly. Those who want larger paychecks treat more patients. Those who are content to live on less income schedule fewer appointments. “It allows us to have the practice we want,” said Elizabeth Wilson, one of the 13 partners.

The group also doesn’t vote. “Generally, decisions are by consensus,” Moreton said. “We keep talking until we come to a consensus.”

So far, the recession hasn’t had a big effect on the practice. “We’ve been very fortunate, but we’re watching our expenses,” he said.

At first, people responded to the recession by delaying pregnancies, he said, but that trend is reversing.

Moreton said the group doesn’t rely on advertising to recruit new patients. “Word-of-mouth is our biggest method,” he said. “But we also supported the Susan G. Komen Race for the Cure” event.

Patients are not confined to Mid-Missouri, either.

“We have patients who drive from the Iowa border, from Hannibal and the Lake of the Ozarks,” he said. “We have a large catchment area. There are a lot of small-town family physicians who refer their patients to us.”

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Over the years, birthing babies has grown more complex, not less.

Today, more women have diabetes, hypertension, heart disease and obesity when they become pregnant. And women are starting their families at later ages, too.

“The whole population is sicker than it was 20 years ago,” Moreton said. “And infertility is more successfully treated than it used to be. The list of complications is longer and more serious.”

Morse, who attended medical school at Saint Louis University and did her residency at Parkland Hospital in Dallas, said a baseline level of anxiety is just a part of the job. But she enjoys the work for its variety and challenge.

She spends most of her days in the clinic, unless she is called to delivery, and one day a week is scheduled for gynecological surgery.

“Every day is a little bit different because you don’t know when a baby is going to come,” she said.

On one hand, managing a high-risk pregnancy is stressful, worrisome and exhausting. On the other hand, it’s an electrifying challenge that brings out a doctor’s best efforts.

“It is challenging, and it does require you to use all your skills to guide patients through a risky experience, but when you succeed, it’s quite rewarding,” Moreton said.

Trammell has found himself nervously pacing the hospital and praying for a good outcome more times than he could remember.

All the doctors interviewed said they’ve experienced so many highs and lows on the job it’s hard to distinguish the individual cases. “There’s so many; it would be impossible to sort out one,” Trammell said.

McDavid said every obstetrician has experienced cases where things appeared to be going swimmingly, but the “bottom falls out.”

“It’s like you’re an air traffic controller or a police officer,” he said. “You’re trained to react swiftly. You might have to do a C-section in three minutes.”

But he said obstetricians are trained to make those split-second decisions. “That’s what the training is for,” he said.

For Trammell, the best part of the job is watching the transition a young woman makes when she becomes a mother. As soon she holds her baby for the first time, there is a moment of great joy and peace.

“You can see it in her face. It’s biology. But that’s what it’s all about,” he said.

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